Friday, October 15, 2010
Thursday, January 21, 2010
Life in the "e.r." Sheds Light on the Healthcare Debate
He was the beginning of the 10-hour shift in this level two trauma center, and she the end.
I just clocked in and the e.r. charge nurse called me to trauma room two. I tossed my coat into a chair and rushed in to see the paramedics transferring a 19 year old young man to our bed. He was bleeding from an obvious gunshot wound, GSW, to the right flank. The "two dude brothers" had struck again. The notorious "two dudes" are in every city. And they are tough guys too. This patient, with his numerous gang tattoos and with the attitude that typically flows from his chosen profession related how he was minding his own business when these two dudes began to hassle him. In the end one pulled a gun and put a 9mm shell into his side. The patient was rude even cursing the people who were trying to help.
He was quickly stabilized with fluids and given medications for pain and a tetanus shot. Since he was stable, we ordered a CT scan prior to surgery. About this time his mother arrived. She, unlike her son, was gracious and treated the medical team with respect. She was afraid, as any mom would be. We comforted her and assured her he was getting the very best care possible. We felt sorry for her for the life her son had chosen. Despite his choices, this mother loved her son and even our best efforts to convince her that he would be ok, appropriately failed. She was scared and in our conversation I realized she had been scared for him for a long time. She was a single mom, living on little and raising a kid in a bad part of town. As we chatted the nurse came in with the radiologists interpretation of the CT scan. Unlike many other more unfortunate GSW victims, the scan showed no vital organ or vessel injury. He would be ok.
As I related the news to his mom, she wondered aloud how she would ever pay for his care. I assured her none of us worried about that. Truthfully we didn't. We never did. Patients with little intent to pay roll in to the "e.r." all the time and we never turn them away. And this kid, despite the choices he made that put him in my "e.r." got world-class healthcare that night.
It made me wonder throughout the rest of my shift if government run healthcare would solve the problem. At least the team would be compensated at a little for the effort to save this guys life.
My last patient brought me back to reality. She was a 44-year-old mother of four young children, all of whom accompanied her to the "e.r." that night. Three days prior she finished her last round of chemotherapy for breast cancer and now had developed the dreaded post chemo fever, or neutropenic fever. This is a condition caused by the side effects of the chemo. It kills off your infection fighting neutrophils, a type of white blood cell, rendering the person susceptible to infection and death. We placed her in isolation, started antibiotics and began to search for the cause of the infection with labs and x-rays.
It seemed she had no family history of breast cancer. The findings were discovered by a routine mammogram order by her by-the-book family practice physician. They caught the disease early and a resection of the tumor and surrounding lymph nodes gave a good prognosis. With the added protection of a few rounds of chemo, she had a better than 95 % chance of survival. Had the mammogram not been done, the diagnosis would certainly have been delayed; her prognosis much worse.
She too was rapidly stabilized, and with a few medications and fluids was feeling and looking much better. The kids, who had played quietly in a corner of our waiting room and their dad, were glad to hear we discovered the cause and were quickly killing the infection with antibiotics. As I finished her admission paperwork I realized my shift had ended 45 minutes prior. I gathered up my things and walked to the car.
Obamacare would clearly help me get paid for caring for both of these patients. And with its initial enactment my revenue would probably increase. The second order effects on how the government would then control price and in the end lower my reimbursement faded out of thought as I considered my last patient. She was a victim of a disease that struck her despite good health and life choices. She had a loving family who cared a great deal for her as much as the mother of the gangbanger who started my shift. But under a healthcare system where the government sets the price, shortages lead to postponement of screening procedures. This is the only explanation for why breast cancer mortality is 46% in the UK, a government run rationed healthcare system, and the US where the mortality rate is only 25%. Somehow, despite people's inability to pay, we save more lives than they do.
In both the current system and Obamacare, the gun shot victim gets care. But not so the breast cancer victim or the prostate cancer victim; their survival relies on early detection. When it comes to early detection, our current model works best. Our healthcare system is broken in many ways. But a complete government take over will not work. Patients like this young mother would die an early and unnecessary death. Obamacare is not the answer.
Mark Green MD
Dr. Green is the special operations flight surgeon that had a 5 and 1/2 hour conversation with Saddam Hussein on the night of his capture. Read Dr. Green's account of the experience, and the special operations missions, which led to their meeting in his recently published book, A Night with Saddam. He currently serves as the president of MD-Partners an emergency department management and leadership company.
Thursday, December 31, 2009
The EF Hutton Principle
When I consider our international relations it's hard for me to not see the world like business. Forgive me but I am a businessman. I understand the analogy breaks down at some levels, but bear with me a second.
In the world today we have strategic partners who share a common vision. Much like in business we want to keep them on our side, assisting us in realizing the vision we have for the country and the world we live in. We also have competitors. These people have visions for their countries, which as they execute their vision, keeps us from achieving our own.
One of the critical aspects in business is the ability to influence. Whether it is being the person who sets the agenda, or recruiting a partner to assist you in a venture or task, or convincing your competitor to not pursue a certain product or service, in business, how your partners and competitors view your position in the market place determines your ability to influence them as well as the environment in which you compete/practice. My business strategy for my company is set based on what I believe my partners and competitors will do. They thus cultivate their perception in order to influence what I do to their advantage.
EF Hutton, a financial services company summarized this influence in a TV commercial they did years ago. Two people would be in a crowded noisy room and one would say, my broker is EF Hutton, and EF Hutton says,...and the entire room stops. They lean toward the person waiting with held breath to hear what EF Hutton had to say. Now that is influence.
The United States' ability to influence both our strategic partners and our competitors in the world of geopolitics depends significantly on how they view us. More specifically, how they view, the President of the United States. Our competitors advance their agenda and world vision based in very large part on how they perceive the President will act.
Obama had the world's attention. He swept into office with a message of hope and change and the world was listening. And now, in just under one year, that influence is gone.
Our competitors are seeing the opportunity to advance their world vision at breakneck pace because they view this president as, at a minimum indecisive, but more likely incredibly weak.
Mr. Obama clearly believes apologizing [1], pulling back missiles [2], zeroing our nuclear arsenal [3], not sending troops in a timely fashion when asked for them by the commander he charged with a specific strategy to win in Afghanistan [4], not recognizing obvious acts of terrorism as such [5], and failing to address an obvious attempted attack on the US with explosive underwear [6] will somehow reverse the loss of influence, which occurred during President Bush's tenure. Unfortunately, these actions have only exponentially decreased our influence in the world. Just look around.
Iran has continued to thumb its nose at the UN and us. Ahmadinejad recently said Iran would not comply with the UN deadline of 31 DEC [7]. They are now busted attempting to bring a huge shipment of uranium into the country against UN resolutions [8]. Worse, as protestors in Iran are being driven over by government trucks [9], our president says nothing.
America is not setting the agenda or the debate. In fact we are not even responding
When Mr. Obama decided to remove the missile shield destined for Poland and Czechoslovakia, it was articulated that the Iranian threat was different requiring a system based from ships [10]. This may be true. But in the art of statecraft and geopolitics, it doesn't matter. The world believes Obama backed down from the Russians. In fact some British are using the word surrender [11]. And what was their response? How have the Russians conducted themselves since?
The Russian leadership announced plans to share arms with Venezuela [12], construct and operate a weapons plant in Venezuela [13], and grow its missile capabilities [14]. Today, Vladimir Putin, perhaps one of the most nationalistic former leaders of Russia, and a man who is expected to run again for president voiced that Russia plans to build more missiles in order to "keep America from doing what it wants to" [14].
Our strategic partners have lost hope too, giving Obama an "F" in protecting the American people [15]. Even the British government is now critical of how Obama has handled the Afghanistan troop delay [16]. Even the French, who were gaga over Obama as he entered office, are now turning on him as a weak leader [17].
As this president fails to understand and articulate that other countries desire greater positions of influence at the expense of our ability to influence, we are destined to find our influence slowly whittled away to nothing. Every concession and every apology is seen by our competitors as an opportunity to position their selves for greater influence. Every step Obama makes slides us further away from the ability to dictate the debate, the issues, and the outcomes of international issues. We grow weaker while our adversaries grow stronger. Obama needs to change, or we need to make a change. We need an EF Hutton and we don't have one.
7 http://tiny.cc/IncVz
13 http://en.rian.ru/russia/20070806/70445720.html
Friday, December 18, 2009
I Told You So
Well, I don't like having to say it. In fact I wish I, and others like me were wrong.
But we were not. Churchill was not. In fact, after going to school with Nikita Khruschev, Kennedy was not. (See blog below on Kennedy, Khruschev, Obama and Ahmadinejad).
Weakness led Hitler to, after getting a pass in the Sudetenland and Austria, invade Poland. Weakness shown on the world stage has led Ahmadinejad to seize Iraqi Oil fields. That's right, just today armed Iranian soldiers seized an oil well in Iraqi territory. Here is the intro to an article:
NASIRIYAH, Iraq (AFP) – Iranian soldiers took control of an Iraqi oil well on a disputed section of the border on Friday, triggering the ire of Baghdad which demanded their immediate withdrawal.
"Iraq demands that Tehran pulls back the armed men who occupied well No. 4... because what happened today is a violation of Iraqi sovereignty," government spokesman Ali al-Dabbagh told AFP. [http://tiny.cc/dGv9v]
I think we all know Mahmoud would not take such a daring move if the cowboy were still in office.
Not that I want the cowboy back. I just want a commander in chief that shows some strength so that bullies like this will always know an act of aggression will be met with the full might of the US Military. That is how you prevent stuff like this from happening in the first place.
As I said in my last blog, I hope Obama learns fast. Who knows what is next?
Mark
Tuesday, December 1, 2009
Kennedy and Khruschev, Obama and Ahmadinejad
Barrack Obama needs to learn the lesson Jack Kennedy learned early in his Presidency or the US and the world are in desperate trouble. In 1961, communism and the USSR were rapidly adding countries to their sphere of influence. Cuba, Laos and others fell to communist rule with increasing speed, and increasing risk to the US. Soviet Premier Nikita Khruschev already issued his infamous decree that western powers were to leave Berlin. The US experienced two aircraft shot down over Soviet airspace in the campaign year of 1960. In this caldron, JFK got himself elected with spirited rhetoric of how the Eisenhower administration had allowed the Soviets to outpace the US in the Cold War, citing Winston Churchill so much that his platform became know as the "Churchill ticket."
However, Kennedy's initial actions at the helm of the US Government were major mistakes, which brought the US to the brink of war. Luckily, he learned his lesson before it was too late. In an effort to secure a working relationship with Khruschev, Kennedy, through back channels with the Soviets, proposed a meeting between he and Khruschev. As the meeting was being clandestinely planned and then overtly conducted, Kennedy made three critical mistakes. First, he ordered the Bay of Pigs Invasion of Cuba, but when the CIA's insurgent forces met heavy resistance, failed to continue the support. The men were easily defeated. The world knew he had started a war, and then backed down.
Secondly, in preparation for a meeting with Khruschev in Vienna, Kennedy, again through back channel means, attempted to secure agreements on a nuclear test ban. "Kennedy inadvertently communicated to Khruschev a number of important things about himself: that in the aftermath of Cuba, he was nervous that Vienna be perceived as a success; that in order to come home with a deal, he was willing to make deep compromises; ...that, rather than acting decisively according to his convictions, he preferred to seek political cover; and that he was willing to deceive the American people, who at his instigation were to be told that the offer of ten inspections had come from the Soviet negotiators rather than from him. In sum, he bared his vulnerabilities to an opponent well able to take advantage of them."[Leaming, 293].1 Only days prior to leaving for the meeting, JFK attempted on two different occasions to schedule a private meeting with the Soviet Premier, without the presence of their respective negotiating teams. Yet both communications went unanswered. It seems Khruschev was not impressed and felt Kennedy weak and unimpressive.
At Vienna, JFK only reinforced Khruschev's opinion of him. "Kennedy, persuaded that no topic could be more important than the need to avoid accidental war, doggedly returned to [the topic] after lunch. Long possessed of the ability to charm others by mocking himself, he offered as an example of a great power's miscalculation his own recent blunder in Cuba. Through the years, most people had found Jack Kennedy's ability to laugh at himself irresistible - but not Khruschev. To Kennedy's immense frustration, Khruschev, completely impervious to his charm, perceived any confession of ones own mistakes as evidence of weakness."[Leaming, 303] 1 Kennedy left Vienna with no agreements from Khruschev, and only a demand that the US leave Berlin.
The ultimate effects of Kennedy's well meaning, but ignorant blunders were profound. The Berlin Crisis would engulf Europe as the Soviet negotiations with East Berlin led to the complete closure of ground access to the beleaguered and surrounded Berlin. Only this time, unlike in Cuba and the Bay of Pigs, Kennedy stood firm. He called up National Guard and reserve units and increased the size of the military. He initiated over flights into Berlin, which kept the isolated people and US forces there supplied. Eventually the East Germans and the Soviets backed down. Later, again tested by Khruschev, Kennedy stood firm. The Cuban Missile Crisis brought the world to the brink of nuclear war. Many speculate Khruschev's placement of Soviet nuclear missiles in Cuba, only 90 miles off the coast of Florida, was a result of the weak image Khruschev formed in his early dealings with JFK. However, in the end, Kennedy learned the lesson, stood firm, and the Soviets backed down and removed the missiles from Cuba.
Barrack Obama's actions on the world stage reflect a similar naivety. He has made numerous mistakes communicating weakness to people who desire our downfall. His speeches, from his initial video on Arab TV in the first week in office, to speeches in Egypt, Strasburg, and Prague were viewed as apologies for America's mistakes. While President Obama meant them as a self-deprecating effort to connect with people, whom he wanted a dialogue, much like Kennedy did with Khruschev, the reception from those people has been just the opposite.
But President Obama has taken it a step further. His Speech in Prague included a promise to zero the US Nuclear arsenal. That speech was made four hours after Kim Jung Il, the President of North Korea, fired a missile over our ally Japan, halfway to the US, all while diplomats from Iran carefully watch. Further, only one week after Putin and Chavez agree to a deal on nuclear energy, President Obama, on the insistence of the Russians, cancels the deployment of a missile defense system in Poland and Czechoslovakia.8 He does this on the exact date of the 70th anniversary of the Soviet invasion of Poland.
His indecisiveness on Afghanistan has communicated tremendous weakness. The commander in the field has communicated we need more troops and casualties mount. Meanwhile the president failed to act. As the media pressed on the issue, the White House finally articulated that a plan was forthcoming, and the delay was due to a desire on the President's part to have an exit strategy. There are a number of issues here that embolden our enemy. First, the fact that we need an Afghanistan surge is a plus in their column. That the president is willing to leave a commander with inadequate resources while soldiers are dying at an increased rate communicates Mr. Obama may be more concerned about perception than the lives of soldiers. It is hard to explain away the delay. Lastly, that no increase could happen without a clear-cut exit strategy communicates a lack of commitment to the cause or vision. Send the troops to help those already down range and plan the exit strategy as they get there. But send the troops! The leaders of Iran, North Korea and Venezuela are not ignorant. Like Khruzchev, they are connecting the dots.
Further, Obama's handling of legal issues as it relates to the GWOT is communicating weakness. His insistence of the Senate to delay investigating the perpetrator of the Fort Hood massacre, and his insistence not to label it an act of terror, despite the man's yelling Allah Akbar as he gunned down US Soldiers is a compelling indictment of the President. While Obama found it easy to assume the Boston Policeman was a racist, assuming this self-professed "Soldier of Allah" was a terrorist was somehow a rush to judgment? Further, the movement of the 9-11 terrorists for trial in New York City gives the enemy the message they have nothing to fear from Barrack Obama and the United States. I wont go into how this trial allows terrorist lawyers access to our nations greatest secrets through the judicial process of discovery. Maybe I'll blog on that later.
Some might ask how I can be so sure the enemy sees Obama as weak? Well the headlines indicate it almost daily. Here are some Headlines from this past week:
"Iran to build 10 uranium sites in defiance of the UN"2
"Chavez welcomes Ahmadinejad to Venezuela."3
"Iranian lawmaker: Iran could leave Nuclear Treaty."4
"Should China Treat North Korea as an Ally"5 This is a UPI Asia article that details a recent trip by the Chinese Defense Minister, 22 Nov 09, where he articulated a commitment to military cooperation.
While the incident with regard to North Korea's Missile launch occurred in April, it is important to note North Korea's response one week after Obama announced he would destroy our Nuclear Weapons - "North Korea Vows to Restart Nuclear Program"6
Yet, even our allies are beginning to see the weakness and it's impact on our national security, as well as their own. Bob Ainsworth is Britain's Defense Secretary. Mr. Ainsworth recently criticized the administration for its delay, an unprecedented move from one of our staunchest allies. "A 'period of hiatus' in Washington - and a lack of clear direction had made it harder for ministers to persuade the British public to go on backing the Afghan mission in the face of a rising death toll, he said."7 The last thing we need is further erosion of allied support in the war zone. The Taliban is a threat to the world. We need the world's support to continue to box them into the remote desert regions of Waziristan. And the world needs a resolute leader in Washington to continue its support of the US.
It is my desire to see Obama learn the lessons of Statecraft. His apologies, like those of President Kennedy to Premier Khruschev were weak and ineffectual. In fact, they led to the opposite response. Should Iran, the supporter of numerous suicide bombings of US interests over the years, Khobar Towers and the Beirut Marine Barracks to name a few, develop nuclear weapons, the Cuban Missile Crisis will pale in significance to the trouble we will face. Obama needs to, like Kennedy, realize that some bullies need to be intimidated. Further, while the world may sometimes fret over our doing so, in the end, a strong America gives them a sense of security and safety. Our President needs to learn fast.
Mark Green MD 30 NOV 09
1Leaming, Barbara, Jack Kennedy, Education of a Statesman, W. W. Norton: 2006.
2http://news.sky.com/skynews/Home/World-News/Iran-To-Build-10-New-Uranium-Enrichment-Plans-State-Media-Has-Announced/Article/200911415478325?lpos=World_News_Carousel_Region_0&lid=ARTICLE_15478325_Iran_To_Build_10_New_Uranium_Enrichment_Plans%2C_State_Media_Has_Announced
3http://edition.cnn.com/2009/WORLD/americas/11/25/iran.ahmadinejad.venezuala/index.html#cnnSTCText
4http://news.yahoo.com/s/ap/20091128/ap_on_re_us/iran_nuclear
5http://www.upiasia.com/Politics/2009/11/30/should_china_treat_north_korea_as_an_ally/5108/
6http://news.aol.com/article/north-korea-nuclear-program/428194
7http://www.telegraph.co.uk/news/newstopics/politics/defence/6646179/Bob-Ainsworth-criticises-Barack-Obama-over-Afghanistan.html
8http://www.reuters.com/article/worldNews/idUSTRE48O5QS20080925?feedType=RSS&feedName=worldNews
Wednesday, November 18, 2009
Second Order Effects of the Public Option - An Economist's Perspective
I got into a recent discussion with a first order thinker. A first order thinker is someone who sees only the initial effects of a decision and fails to look two to three or more chess moves away. The discussion was regarding the public option in Obamacare. I thought I would share my short response to the individual here.
Sure a public health insurance plan would provide low cost health insurance to people in need. That first order effect is good. However, in previous posts I have discussed the second and third order effects of how low cost health insurance incentivizes excess medical care costs. Please see my last few blogs on health care. I won't waste time on that here.
If the government option stays in, business will have the option to pay a fine or provide health insurance. So far, that fine appears to be lower than the cost of healthcare for most business. These businesses would be incentivized to cut their costs to be competitive and would just pay the fine, not providing healthcare. This impacts both the providers of healthcare and the health insurance business and its remaining customers.
The effect on healthcare providers: This would significantly push many people in the private health insurance market to the public option. Since the "public option" would really be a government run business, they would, as they have with Medicare and Medicaid, fix the price low, similar to rent control.
Typically when a price is forced low, the supply of individuals willing to provide the service at that controlled price falls and the demand grows (in the case of healthcare paid by the government - free, that demand grows exponentially).
With the lower price from Medicaid and Medicare, physicians and healthcare people have been able to shift costs to people with private insurance, thus making up for the loss from the lower fixed revenue from government payers. This approximates the real set price, and thus the supply of providers has not taken the same hit, as rental unit supply in cities with rent control. For more on the problems this has caused the heath care system see the blog below.
However, if the pool of individuals on the forced lower rates grows and the pool of people on the private insurance companies falls, the ability to shift costs will dramatically effect the overall revenue produced in the business and thus will significantly impact the supply of people willing to provide heathcare at the new reimbursement rates forced by the government payers.
The cycle would further spiral out of control due to the impact on private insurance. As fewer people purchase private insurance, and as costs are further shifted to them, the price for insurance will continue to skyrocket. As this happens more people will bail to the public option, further driving the spiral.
It is not difficult to envision, with a little common sense, the end result of the public option as it is currently written is single payer system. Which, interestingly enough, President Obama has been video taped articulating as his ultimate goal.
Friday, October 2, 2009
A Plan For Fixing Health Care
Several people have asked me to put my thoughts on Obamacare and the current healthcare situation in the US in a single blog. This is an effort to summarize my thoughts and share my solution for phase one of fixing the current problems.
Most Americans want to help the disadvantaged and the elderly acquire quality healthcare. No one argues that the current system is not broken. Yet the solutions being discussed now all fall prey to the same underlying principles, which led to our current healthcare crisis.
There are primarily three major issues with the current US Healthcare system. The first is inherent in the basic human response to incentives. Another is the impact of government price fixing and it's impact on health insurance. Lastly, defensive medicine is adding costs to those who ultimately pay the price for everyone's health program.
When government or any entity picks up the cost of someone's healthcare, the result is a lack of concern for costs. People become incentivized to spend. In many cases, they spend well beyond what they would be willing to pay themselves even if they had the resources. With no cost barrier, and as the supply demand curve of economics 101 shows, demand exponentially increases as the price falls. At zero price, or free, demand is infinite.
Concomitantly, the supply curve falls leading to a significant shortage. Or, in other words, when there is no cost barrier, there is no end to the demand. With unlimited demand, there is no supply that can ever meet the demand.
The evidence of this is easy to find by looking at a healthcare system where 100% of people are covered for "free.". In England, mortality rates for most diseases significantly exceed the US. Two examples are prostate cancer, mortality is 19% in the US and 56% in the UK, and mortality for breast cancer in the US is 25% while in the UK it is 46%.1 As demand exceeds supply rationing, or whatever politically correct word you chose, must occur. The consequence is a system where screening occurs later in life. Early detection is essential to cure in nearly everything. A shortage of caregivers will lead to increased mortality and poor quality.
Current abuse of the emergency department and other visits to physicians for conditions that our grand parents would treat on their own is taxing the system substantially. Much of the increased costs in our current system are due to unnecessary visits. For those on "free" or low cost systems, there is no incentive to save, and again no supply that can ever meet the demand.
An additional problem to the current system is the effect on health insurance and other payers when government sets the price so low. When Medicare and Medicaid say, we will only pay X for this procedure, and X is substantially below the market equilibrium price, one of two things happens. Either providers stop doing that service, or in economic terms stop supplying that service at the set price. Or, they increase the price charged to others, a process called cost shifting.
The effect of cost shifting has devastated the Health Insurance Industry. As the government pays less, physicians, hospitals and other healthcare entities raise the price for others leading to increased cost of care for those with health insurance. This increase is then in turn passed to their customers in increased cost. As the cost escalates, fewer people can purchase health insurance leading to a need for insurance companies to increase prices further. What followed was a vicious cycle and put us where we are today.
There is a tendency to place the blame on health insurance profits and their executive salaries. I often as a physician have fallen into that trap only to catch myself. It is an easy fallacy to get into. But if you look at Kroger Foods, a company that supplies...food, its net income was $1.18 billion dollars and the CEO was paid $2.78 million.2 How is healthcare so much more essential than food? Why is the standard any different? Health insurance reforms of the late 1980's and early 1990 lead to significant reductions is cost as they regulated the use of expensive medications and procedures. Their involvement in healthcare has decreased not increased costs. Cost shifting because the government forcibly set the price low is the primary cause of the problem.
Essentially, with Medicare and Medicaid price fixing, the free market in healthcare is dead. The free market will drive price down for everyone. LASEK is an excellent example. LASEK involves a very precise "laser," trimming microns of cornea to reshape the cornea and focus the image on the retina. Health insurance and government medical care do not cover the price of this procedure. Meaning true market forces are setting the price. What has happened? When LASEK was introduced it cost $5,000 to $6,000 dollars. I saw an ad yesterday for LASEK for $499 per eye. Granted the average LASEK procedure is roughly $1,800 dollars, but even this amount is significantly less than where it started. As ophthalmologists competed for the dollars people were willing to spend, the price fell. This year's average was less than last year's. This decrease in the average cost of a surgical procedure on the eye happened in the face of an increase in healthcare costs that was twice the rate of inflation.
An added dimension to the impact this has is the simple fact that health insurance companies are not allowed to compete across state borders. Meaning BlueCross/Blue Shield operates offices in each state with added costs of doing so. And with a limited number of competitors, there is no incentive to the insurance companies to reduce costs. Lifting the ban on interstate competition would significantly incentivize insurance companies to reduce their costs. Wal-Mart is an excellent example of a company able to decrease costs, and continue to profit because of volume.
We need to compel the government to stop fixing the price. The free market will adjust itself and with competition find a price at a supply demand equilibrium point. Great examples are rent control. Whenever states repeal rent control laws, the supply of housing increases and the price actually falls. This new healthcare equilibrium price will no doubt be significantly less than what the insurance companies are providing. This will, with allowed competition, significantly decrease the price of health insurance and thus increase the pool of people able to afford it. And with appropriate incentives detailed below, would decrease the misuse and thus cost of unnecessary medicine. This would free government dollars to pay the slightly higher market price for necessary procedures.
Liability reform is a major area for saving billions of dollars. No one wants to be sued. In some states, like Florida, three suits and you lose your license; there is a defined limit on the number of lawsuits you are allowed. Further, who wants to endure the costs in life sacrifice and money to get through medical school only to lose it all in a single settlement? A recent lawsuit paid a patient $60 million dollars when the plastic surgeon botched her thigh lift.3 Frivolous lawsuits and exorbitant awards cost providers and their insurance companies millions of dollars in insurance premiums. Those costs are forwarded on to the patients in increased healthcare costs and thus increased insurance premiums. But what does it do to the doctors? We go crazy ordering CAT scans and labs to make certain that once we are on the stand, we can say we did everything we could. Those additional studies intended to keep my colleagues and I out of the courtroom, are the heart of defensive medicine.
In a recent poll of emergency physicians, 65% said that they could save over $500 per 8-hour shift by decreasing unnecessary tests as a part of their defensive practice. Another 16% felt they could save between $200 and $500 dollars.4 I run a fairly large Level 2 trauma center that will see 75,000 patients this year. I staff it with 9, 10 and 12-hour shifts a day. If we assume a conservative savings per shift of $400 dollars, less than a single CAT scan, then in my emergency department alone, stopping the defensive practice of medicine would save (365 x 9 x $400) $1,314,000.00. There are over 5,000 emergency departments in the country.
But how can you have a government run program to help people who need assistance, and yet allow free market practices set the price? The government already has a program in place that does just that.
The food stamp program, now called the Supplemental Nutrition Assistance Program, or SNAP, is where 31.5 million Americans receive assistance to purchase food. This program is an excellent paradigm for healthcare. People who qualify are given a debit card and allowed to purchase the food they desire. The market price for food remains unchanged for the most part because the consumer is choosing how to allocate the resources he or she has. The consumer recognizes there is a limited amount and thus chooses prudently on how to spend the money. If they foolishly buy filet mignon, they have little to nothing else for the remainder of the month.
Healthcare credits via a debit card would place the decision-making back in the hands of the consumer. We have the actuarial data and can calculate the exact amounts needed to be kept in reserve for catastrophic care. The money used for routine visits as well as non-emergent use of the emergency department can be allocated to the health debit cards. The government would issue qualifying personnel a set amount yearly in conjunction with a catastrophic health plan. The individual would chose to save money by waiting to go to a primary care doctor instead of an emergency department and thus have money remaining for preventative care should they desire it. The individual has a choice, the market forces of supply and demand are thus reinstated and assuredly the right price will surface. As more people pay for their care, and make wise choices in regards to their care, cost shifting will stop and, for competition's sake, could even reverse itself.
Additionally, other incentives would include, all unused healthcare credits at year end could roll over into an IRA, or other vehicles which further incentivize the individual to not abuse healthcare, specifically the emergency department for routine care. Or, the unused amount could be applied for at tax time much like an earned income credit or child credit is received. With the financial incentive to decrease the cost of a person's healthcare, some people would decrease their risk as well, eating better and perhaps ending a nicotine habit. Why not, if they don't get sick, they get the financial reward.
This system reverses the current incentive to spend regardless of the cost. It would remove the government from price fixing and thus allow the market and competition to push the price down. Lastly, coupled with real tort reform, physician defensive practices would decrease and significantly enhance savings. What are we waiting for.
Mark
1Healthcare Here and Over There, Investor's Business Daily.http://www.ibdeditorials.com/IBDArticles.aspx?id=334968219359127
2http://finance.yahoo.com/q/pr?s=KR
3"Defensive Medicine is Real," Emergency Medicine Physician Monthly, volume 16, number 9, September 2009. Page 22.
4"What Emergency Physicians think about health care reform," Emergency Medicine Physician Monthly, volume 16, number 9, September 2009. Page 24.
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